Received Red Blood Cell Transfusion Research Articles

A retrospective analysis of venous thromboembolism trends in chemotherapy-induced anemia: Red blood cell transfusion versus erythrocyte stimulating agent administration.

BackgroundPatients receiving a variety of chemotherapy regimens often develop chemotherapy‐induced anemia (CIA), which contributes to poor outcomes including increased mortality. Prompt and effective treatment of CIA is essential to prevent fewer chemotherapy dose delays and reductions. Optimal therapy of CIA is controversial and involves the solitary and combined use of intravenous iron, red blood cell (RBC) transfusions, and erythropoietin stimulating agents (ESAs). Despite the baseline coagulopathies present in patients with malignancy, administration of both RBC transfusions and ESAs is associated with venous thromboembolism (VTE). It remains unknown whether the risk of VTE in patients with CIA is greater among patients who receive RBC transfusions or ESAs.MethodsA retrospective study analyzed 10,269 University of Pennsylvania Health System patients with malignancies of various type, stage, and histopathology who developed CIA between 2008 and 2017. Using multivariate Cox regression, we determined adjusted hazard ratios (and corresponding 95% confidence intervals) of VTE development after adjusting for RBC and ESA intervention (all during the 90 days following CIA diagnosis).ResultsAmong the 10,269 patients with CIA, 2,642 (25.7%) developed a VTE within the 90‐day period. VTE risk following RBC transfusion (HR = 1.37, 95% CI 1.24‐1.50, P < .001) was more than twice as common as VTE risk following ESA administration (HR = 0.53, 95% CI 0.40‐0.69, P < .001).ConclusionWhile both RBC transfusion and ESA are independently associated with VTE, our data suggest a greater risk of VTE development with RBC transfusion as compared with ESA.

Timing of Transfusion, not Hemoglobin Variability, is Associated with 3-Month Outcomes in Acute Ischemic Stroke.

Objectives: This study aimed to investigate whether transfusions and hemoglobin variability affects the outcome of stroke after an acute ischemic stroke (AIS). Methods: We studied consecutive patients with AIS admitted in three tertiary hospitals who received red blood cell (RBC) transfusion (RBCT) during admission. Hemoglobin variability was assessed by minimum, maximum, range, median absolute deviation, and mean absolute change in hemoglobin level. Timing of RBCT was grouped into two categories: admission to 48 h (early) or more than 48 h (late) after hospitalization. Late RBCT was entered into multivariable logistic regression model. Poor outcome at three months was defined as a modified Rankin Scale score ≥3. Results: Of 2698 patients, 132 patients (4.9%) received a median of 400 mL (interquartile range: 400–840 mL) of packed RBCs. One-hundred-and-two patients (77.3%) had poor outcomes. The most common cause of RBCT was gastrointestinal bleeding (27.3%). The type of anemia was not associated with the timing of RBCT. Late RBCT was associated with poor outcome (odd ratio (OR), 3.55; 95% confidence interval (CI), 1.43–8.79; p-value = 0.006) in the univariable model. After adjusting for age, sex, Charlson comorbidity index, and stroke severity, late RBCT was a significant predictor (OR, 3.37; 95% CI, 1.14–9.99; p-value = 0.028) of poor outcome at three months. In the area under the receiver operating characteristics curve comparison, addition of hemoglobin variability indices did not improve the performance of the multivariable logistic model. Conclusion: Late RBCT, rather than hemoglobin variability indices, is a predictor for poor outcome in patients with AIS.

Optimizing Perioperative Red Blood Cell Utilization and Wastage in Pediatric Craniofacial Surgery.

Utilization, wastage, and adverse consequences of assigning one full red blood cell (RBC) unit were investigated for children undergoing craniosynostosis surgery. The authors hypothesized that significant RBC wastage in the perioperative period exists for pediatric craniofacial surgery. The authors sought to determine what factors could guide patient-specific blood product preparation by evaluating utilization and wastage of RBCs in pediatric patients undergoing surgical correction of craniosynostosis. Eighty-five children with craniosynostosis undergoing surgical correction at our institution between July 2013 and June 2015 were identified. Fifty-three patients received RBC transfusion in the perioperative period, while 32 patients were not transfused. Primary outcome measures were intraoperative, postoperative, and total percent of RBC wastage. Secondary analysis compared the impact of patient weight and procedure type on perioperative RBC wastage. Of the 53 patients who received perioperative RBC transfusion, 35 patients received a volume of blood less than the full volume of the RBC unit while 18 patients received the full volume of blood. There was no significant relationship between perioperative RBC wastage, the type of craniofacial procedure performed, or the duration of surgical time. Children who received a perioperative transfusion and had RBC wastage weighed significantly less than those who received a full volume. These findings suggest that for craniofacial surgical patients weighing less than 10 kg, a protocol that splits cross-matched RBC units can decrease perioperative RBC wastage and blood donor exposure. A future prospective study will determine the success of this intervention as well as the potential to decrease exposure to multiple blood donors.

Reducing the red blood cell transfusion threshold from 8·0 g/dl to 7·0 g/dl in acute myeloid leukaemia patients undergoing induction chemotherapy reduces transfusion rates without adversely affecting patient outcome.

Red blood cell (RBC) transfusions are needed by almost every acute myeloid leukaemia (AML) patient undergoing induction chemotherapy and constitute a cornerstone in supportive measures for cancer patients in general. Randomized controlled trials have shown non-inferiority or even superiority of restrictive transfusion guidelines over liberal transfusion guidelines in specific clinical situations outside of medical oncology. In this study, we analysed whether more restrictive RBC transfusion reduces blood use without affecting hard outcomes. A total of 352 AML patients diagnosed between 2007 and 2018 and undergoing intensive induction chemotherapy were included in this retrospective analysis. In the less restrictive transfusion group, patients received RBC transfusion for haemoglobin levels below 8g/dl (2007-2014). In the restrictive transfusion group, patients received RBC transfusion for haemoglobin levels below 7g/dl (2016-2018). Liberal transfusion triggers were never endorsed. A total of 268 (76·1%) and 84 (23·9%) AML patients fell into the less restrictive and restrictive transfusion groups, respectively. The less restrictive transfusion group had 1g/dl higher mean haemoglobin levels, received their first RBC transfusions earlier and needed 1·5 more units of RBC during the hospital stay of induction chemotherapy. Febrile episodes, C-reactive protein levels, admission to the intensive care unit, length of hospital stay as well as response and survival rates did not differ between the two cohorts. From our retrospective analysis, we conclude that a more restrictive transfusion trigger does not affect important outcomes of AML patients. The opportunity to test possible effects of the more severe anaemia in the restrictive transfusion group on quality of life was missed.

The effect of restrictive versus liberal transfusion strategies on longer-term outcomes after cardiac surgery: a systematic review and meta-analysis with trial sequential analysis.

Blood transfusions are frequently administered in cardiac surgery. Despite a large number of published studies comparing a "restrictive" strategy with a "liberal" strategy, no clear consensus has emerged to guide blood transfusion practice in cardiac surgery patients. The purpose of this study was to identify, critically appraise, and summarize the evidence on the overall effect of restrictive transfusion strategies compared with liberal transfusion strategies on mortality, other clinical outcomes, and transfusion-related outcomes in adult patients undergoing cardiac surgery. We searched MEDLINE (OvidSP), EMBASE (OvidSP) and Cochrane CENTRAL (Wiley) from inception to 1December 2017 and queried clinical trial registries and conference proceedings for randomized-controlled trials of liberal vs restrictive transfusion strategies in cardiac surgery. From 7,908 citations, we included ten trials (9,101 patients) and eight companion publications. Overall, we found no significant difference in mortality between restrictive and liberal transfusion strategies (risk ratio [RR], 1.08; 95% confidence interval [CI], 0.76 to 1.54; I2 = 33%; seven trials; 8,661 patients). The use of a restrictive transfusion strategy did not appear to adversely impact any of the secondary clinical outcomes. As expected, the proportion of patients who received red blood cells (RBCs) in the restrictive group was significantly lower than in the liberal group (RR, 0.68; 95% CI, 0.64 to 0.73; I2 = 56%; 5 trials; 8,534 patients). Among transfused patients, a restrictive transfusion strategy was associated with fewer transfused RBC units per patient than a liberal transfusion strategy. In adult patients undergoing cardiac surgery, a restrictive transfusion strategy reduces RBC transfusion without impacting mortality rate or the incidence of other perioperative complications. Nevertheless, further large trials in subgroups of patients, potentially of differing age, are needed to establish firm evidence to guide transfusion in cardiac surgery. PROSPERO (CRD42017071440); registered 20 April, 2018.

Decision Tree-based Modelling for Identification of Predictors of Blood Loss and Transfusion Requirement After Adult Spinal Deformity Surgery.

Multilevel fusions and complex osteotomies to restore global alignment in adult spinal deformity (ASD) surgery can lead to increased operative time and blood loss. In this regard, we assessed factors predictive of perioperative blood product transfusion in patients undergoing long posterior spinal fusion for ASD. A single-institution retrospective review was conducted on 909 patients with ASD, age > 18 years, who underwent surgery for ASD with greater than 4 levels fused. Using conditional inference tree analysis, a machine learning methodology, we sought to predict the combination of variables that best predicted increased risk for intraoperative percent blood volume lost and perioperative blood product transfusion. Among the 909 patients included in the study, 377 (41.5%) received red blood cell (RBC) transfusion. The conditional inference tree analysis identified greater than 13 levels fused, American Society of Anesthesiologists (ASA) score > 1, a history of hypertension, 3-column osteotomy, pelvic fixation, and operative time > 8 hours, as significant risk factors for perioperative RBC transfusion. The best predictors for the subgroup with the highest risk for intraoperative percent blood volume lost (subgroup mean: 53.1% ± 42.9%) were greater than 13 levels fused, ASA score > 1, preoperative hemoglobin < 13.6 g/dL, 3-column osteotomy, posterior column osteotomy, and pelvic fixation. Patients who underwent major blood transfusion intraoperatively had significantly longer length of stay (8.5 days) versus those who did not (6.1 days) (P < .0001). The overall 90-day complication rate in patients who underwent major blood transfusion intraoperatively was 49%, compared with 19% in those who did not (P < .0001). By multivariate regression analysis, patients with a preoperative hemoglobin > 13.0 were less likely to require major blood transfusion (odds ratio: 0.52, P = .046). Using a supervised learning technique, this study demonstrates that greater than 13 levels fused, ASA score > 1, 3-column osteotomy, and pelvic fixation are consistent risk factors for increased intraoperative percent blood volume lost and perioperative RBC transfusion. The addition of having a preoperative hemoglobin < 13.6 g/dL or undergoing a posterior column osteotomy conferred the highest risk for intraoperative blood loss. This information can assist spinal deformity surgeons in identifying at-risk individuals and allocating healthcare resources. 3.

Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants.

Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia. Darbepoetin (Darbe) and EPO are currently available ESAs. To assess the effectiveness and safety of late initiation of ESAs, between eight and 28 days after birth, in reducing the use of red blood cell (RBC) transfusions in preterm or low birth weight infants. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 5 June 2018), Embase (1980 to 5 June 2018), and CINAHL (1982 to 5 June 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised controlled trials of late initiation of EPO treatment (started at ≥ eight days of age) versus placebo or no intervention in preterm (< 37 weeks) or low birth weight (< 2500 grams) neonates. We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of the evidence. We include 31 studies (32 comparisons) randomising 1651 preterm infants. Literature searches in 2018 identified one new study for inclusion. No new on-going trials were identified and no studies used darbepoetin. Most included trials were of small sample size. The meta-analysis showed a significant effect on the use of one or more RBC transfusions (21 studies (n = 1202); typical risk ratio (RR) 0.72, 95% confidence interval (CI) 0.65 to 0.79; typical risk difference (RD) -0.17, 95% CI -0.22 to -0.12; typical number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 5 to 8). There was moderate heterogeneity for this outcome (RR I² = 66%; RD I² = 58%). The quality of the evidence was very low. We obtained similar results in secondary analyses based on different combinations of high/low doses of EPO and iron supplementation. There was no significant reduction in the total volume (mL/kg) of blood transfused per infant (typical mean difference (MD) -1.6 mL/kg, 95% CI -5.8 to 2.6); 5 studies, 197 infants). There was high heterogeneity for this outcome (I² = 92%). There was a significant reduction in the number of transfusions per infant (11 studies enrolling 817 infants; typical MD -0.22, 95% CI -0.38 to -0.06). There was high heterogeneity for this outcome (I² = 94%). Three studies including 404 infants reported on retinopathy of prematurity (ROP) (all stages or stage not reported), with a typical RR 1.27 (95% CI 0.99 to 1.64) and a typical RD of 0.09 (95% CI -0.00 to 0.18). There was high heterogeneity for this outcome for both RR (I² = 83%) and RD (I² = 82%). The quality of the evidence was very low.Three trials enrolling 442 infants reported on ROP (stage ≥ 3). The typical RR was 1.73 (95% CI 0.92 to 3.24) and the typical RD was 0.05 (95% CI -0.01 to 0.10). There was no heterogeneity for this outcome for RR (I² = 18%) but high heterogeneity for RD (I² = 79%). The quality of the evidence was very low.There were no significant differences in other clinical outcomes including mortality and necrotising enterocolitis. For the outcomes of mortality and necrotising enterocolitis, the quality of the evidence was moderate. Long-term neurodevelopmental outcomes were not reported. Late administration of EPO reduces the use of one or more RBC transfusions, the number of RBC transfusions per infant (< 1 transfusion per infant) but not the total volume (mL/kg) of RBCs transfused per infant. Any donor exposure is likely not avoided as most studies included infants who had received RBC transfusions prior to trial entry. Late EPO does not significantly reduce or increase any clinically important adverse outcomes except for a trend in increased risk for ROP. Further research of the use of late EPO treatment, to prevent donor exposure, is not indicated. Research efforts should focus on limiting donor exposure during the first few days of life in sick neonates, when RBC requirements are most likely to be required and cannot be prevented by late EPO treatment. The use of satellite packs (dividing one unit of donor blood into many smaller aliquots) may reduce donor exposure.

Influence of enteral feeding and anemia on tissue oxygen extraction after red blood cell transfusion in preterm infants.

Understanding factors that impact tissue oxygen extraction may guide red blood cell (RBC) transfusion decision making in preterm infants. Our objective was to assess the influence of enteral feeding and anemia on cerebral and mesenteric oxygen saturation (Csat and Msat) and fractional tissue oxygen extraction (cFTOE and mFTOE) over the entire time course of RBC transfusion. Preterm, very low-birth-weight infants receiving RBC transfusions at a single center were enrolled. Near-infrared spectroscopy sensors measured Csat and Msat levels from an hour before transfusion to 24 hours after. During this period, changes in Csat, Msat, cFTOE, and mFTOE were described, and their association with enteral feeding status and pretransfusion degree of anemia were assessed using generalized estimating equations. RBC transfusion data from 31 preterm infants were included. Infants receiving enteral feeds exhibited lower pretransfusion Msat. Infants with pretransfusion hematocrit greater than 30% exhibited higher pretransfusion Csat and lower pretransfusion cFTOE. Such differences in baseline measurements persisted through 24 hours after transfusion. However, no statistically significant differences in oxygenation measures over time by enteral feeding or anemia status were identified. Compared to NPO, enteral feeding was associated with lower Msat; anemia (hematocrit ≤30%) was associated with lower Csat and higher cFTOE. Over the time course of RBC transfusion, trajectories of Csat, Msat, cFTOE and mFTOE did not differ by enteral feeding or anemia status.

Cold Agglutinin Disease Transfusion Practices in the United States: An Electronic Medical Record-Based Analysis

Introduction Cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia (AIHA) accounting for 20% of all cases, with no approved therapies and limited management options for patients. CAD is characterized by immunoglobulin M-mediated erythrocyte agglutination, which triggers activation of the classical complement pathway leading to hemolysis and subsequent anemia. Red blood cell (RBC) transfusions are used as a supportive treatment in CAD to temporarily alleviate anemia, although the transfusion practices are variable among providers treating patients with CAD. Recent RBC transfusion guidelines from the AABB (formerly the American Association of Blood Banks) recommend that transfusions be administered with a restrictive threshold in most clinical scenarios (ie, transfusion is not indicated until hemoglobin [Hb] reaches 7-8 g/dL and/or patients exhibit anemia-related symptoms) to avoid associated complications such as acute reactions, alloantibody development, and hemochromatosis (Carson et al, JAMA, 2016; Carson et al, N Engl J Med, 2017). Because of the dearth of information available regarding trends in RBC transfusion practices among US hematologists, the objective of this longitudinal, retrospective, observational assessment of an electronic medical record database was to evaluate transfusion practices applied to patients with CAD in the US. Methods Patients were retrospectively identified from Optum® de-identified Electronic Health Record (EHR) dataset. Adult patients with ≥1 AIHA-related medical encounter between January 2007 and September 2018 (study period) and ≥3 mentions of CAD-related terms from physician notes ("cold agglutinin disease," "cold autoimmune hemolytic anemia," or "cold agglutinin hemoglobinuria") were included (Broome et al, Blood, 2017). The index date for each patient was the date of first mention of CAD during the study period. The baseline period was defined as the interval from the start of medical activity in the EHR database or study period (whichever occurred later) to the index date, and the follow-up period was defined as the interval from the index date to the end of the study period, end of medical activity, or death (whichever occurred earlier). The study sample was categorized into 2 study groups, the transfusion group (patients with CAD with ≥1 RBC transfusion after the index date) and the non-transfusion group (patients with CAD without any transfusions during the study period). Patients were further grouped based on the following Hb levels (g/dL): &amp;lt;8, ≥8 to ≤10, and &amp;gt;10 to ≤12. The closest Hb level prior to the most recent transfusion (within the prior 15 days and the lowest level) was used for the transfusion group and the lowest Hb level during the study period was used for the non-transfusion group. Descriptive statistics included mean, standard deviation, and median values for continuous variables and frequency (n and percent) for categorical variables. No adjustment was made for this descriptive analysis. Results A total of 903 patients with CAD were identified from the Optum EHR database; most patients were white (n=760 [84%]) and female (n=560 [62%]). Baseline demographics and clinical characteristics of each group can be found in the Table. Of the patients with CAD, 548 (61%) did not receive transfusions and 355 (39%) received ≥1 RBC transfusion. Among patients with CAD who received transfusions, 84% (n=297) had ≥2 RBC transfusions. Out of the 903 patients with CAD, 864 had Hb levels reported and 752 had Hb levels ≤12 g/dL. Forty-four percent (n=329/752) of those CAD patients received ≥1 RBC transfusion. When separated by Hb levels, 18% of patients with Hb &amp;gt;10 to ≤12 g/dL (n=19/108); 41% (n=88/216) of patients with Hb ≥8 to ≤10 g/dL; and 52% (n=222/428) of patients with Hb &amp;lt;8 g/dL received ≥1 RBC transfusion. Of the 423 (56%) patients with CAD and Hb levels ≤12 g/dL who did not receive RBC transfusions, 21% (n=89/423) had Hb levels &amp;gt;10 to ≤12 g/dL; 30% (n=128/423) had Hb levels ≥8 to ≤10 g/dL; and 49% (n=206/423) had Hb levels &amp;lt;8 g/dL. Conclusions Overall, patients with CAD are not a heavily transfused population. Even in those with a significantly decreased Hb (&amp;lt;8 g/dL), approximately half of them (49%) did not receive RBC transfusions. This suggests that the use of transfusions in patients with CAD may not reflect disease severity. Further prospective studies are needed to fully understand the impact of transfusions on patients with CAD. Disclosures Su: Sanofi Genzyme: Employment, Equity Ownership. Punekar:Sanofi: Employment, Equity Ownership. Morales Arias:Sanofi: Employment, Equity Ownership. Jain:Sanofi Genzyme: Employment, Equity Ownership.

A 19-Year Retrospective Analysis of Venous Thromboembolism Trends in Chemotherapy-Induced Anemia: Red Blood Cell Transfusion Versus Erythrocyte Stimulating Agent Administration

Introduction: Anemia is a common and unfortunate consequence of chemotherapy; patients receiving a variety of chemotherapy regimens often develop chemotherapy-induced anemia (CIA), which contributes to poor outcomes including increased mortality. Prompt and effective treatment of CIA is essential to prevent fewer chemotherapy dose delays and reductions. Optimal therapy of CIA is controversial and involves the solitary and combined use of intravenous iron, red blood cell (RBC) transfusions, and erythropoietin stimulating agents (ESAs). Despite the baseline coagulopathies present in patients with malignancy, administration of both RBC transfusions and ESAs is independently associated with venous thromboembolism (VTE). It remains unknown whether the risk of VTE in patients with CIA is greater among patients who receive RBC transfusions or ESAs. Methods: A retrospective study analyzed 13,334 patients in the University of Pennsylvania Health System with malignancies of various type, stage, and histopathology who developed CIA between 1998-2017. Using multivariate Cox regression, we determined adjusted hazard ratios (and corresponding 95% confidence intervals) of VTE development after adjusting for RBC and ESA intervention (all during the 90 days following CIA diagnosis). Results: (Table 1) Among the 13,334 patients with CIA, 10,948 patients did not receive any therapy during the 90-day period for their anemia (neither RBC nor ESA), 1,892 received RBC transfusion, 368 received ESA, and 126 patients received both. Among all patients, 2,620 (19.7%) developed a VTE within the 90-day period. VTE risk following RBC transfusion (HR=2.18, 95% CI 1.98-2.39, p&lt;0.001) was approximately four-fold the VTE risk following ESA administration (HR=0.55, 95% CI 0.42-0.72, p&lt;0.001). Conclusion: While both RBC transfusion and ESA administration are associated with VTE, our data suggests a greater risk of VTE development with RBC transfusion as compared with ESA administration. Disclosures No relevant conflicts of interest to declare.

Persistent Red Blood Cell (RBC) Transfusion Is Associated with Increased Mortality Risk in Transfusion-Dependent (TD) Patients with Myelodysplastic Syndromes (MDS) with Ring Sideroblasts (RS+)

Persistent Red Blood Cell (RBC) Transfusion Is Associated with Increased Mortality Risk in Transfusion-Dependent (TD) Patients with Myelodysplastic Syndromes (MDS) with Ring Sideroblasts (RS+)

A 19-year retrospective analysis of venous thromboembolism trends in chemotherapy-induced anemia: Red blood cell transfusion versus erythrocyte stimulating agent administration

Abstract Background Chemotherapy-induced anemia (CIA) contributes to poor patient outcomes and increased mortality. Prompt and effective treatment of CIA is essential to prevent fewer chemotherapy dose delays and reductions. Optimal therapy of CIA involves intravenous iron, red blood cell (RBC) transfusions, and erythrocyte stimulating agents (ESAs). Despite the baseline coagulopathies present in patients with malignancy, administration of both RBC transfusions and ESAs is independently associated with venous thromboembolism (VTE). It remains unknown whether the risk of VTE in patients with CIA is greater among patients who receive RBC transfusions or ESAs and whether or not this risk is consistent across gender and age. Methods A retrospective study analyzed 13,334 patients with various malignancies who developed CIA between 1998-2017. Using multivariate Cox regression, we determined adjusted hazard ratios (and corresponding 95% confidence intervals) of VTE development after controlling for RBC and ESA intervention (within 90 days after CIA diagnosis). Data was then stratified by gender and age ( Results Among the 13,334 patients with CIA, 2,620 (19.7%) developed a VTE. Despite stratification by gender, VTE risk following RBC transfusion was approximately four-fold the VTE risk following ESA administration (Table). Among patients with CIA who were Table: 106P . Treatment and outcomes within 90 days following CIA diagnosis No treatment RBC only ESA only RBC and ESA Patients with VTE (All Patients) 2028 (10,948) 538 (1,892) 42 (368) 12 (126) 18.5% 28.4% (HR = 2.18, 95% CI 1.98-2.39, p 11.4% (HR = 0.55, 95% CI 0.42-0.72, p 9.5% Men with VTE (All male patients) 970 (5428) 269 (917) 21 (182) 5 (61) 17.9% 29.3% (HR = 2.33, 95% CI (2.04-2.67, p 11.5% (HR = 0.55, 95% CI (0.37-0.81, p = 0.002) 8.3% Women with VTE (All female patients) 1058 (5519) 269 (975) 21 (186) 7 (65) 19.2% 27.6% (HR = 2.04, 95% CI (1.79-2.33), p 11.3% (HR = 0.56, 95% CI (0.38-0.81), p = 0.002) 10.8% Conclusions Among patients with CIA, there is an approximate four-fold increased risk of VTE development with RBC transfusion as compared with ESA administration. Legal entity responsible for the study The authors. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.

Effect of red blood cell storage duration on major postoperative complications in cardiac surgery: A randomized trial

BackgroundAlthough observational studies suggest an association between transfusion of older red blood cell (RBC) units and increased postoperative risk, randomized trials have not supported this. The objective of this randomized trial was to test the effect of RBC storage age on outcomes after cardiac surgery. MethodsFrom July 2007 to May 2016, 3835 adults undergoing coronary artery bypass grafting, cardiac valve procedures, or ascending aorta repair, either alone or in combination, were randomized to transfusion of RBCs stored for ≤14 days (younger units) or for ≥20 days (older units) intraoperatively and throughout the postoperative hospitalization. According to protocol, 2448 patients were excluded because they did not receive RBC transfusions. Among the remaining 1387 modified intent-to-treat patients, 701 were randomized to receive younger RBC units (median age, 11 days) and the remaining 686 to receive older units (median age, 25 days). The primary endpoint was composite morbidity and mortality, analyzed using a generalized estimating equation (GEE) model. The trial was discontinued midway owing to enrollment constraints. ResultsA total of 5470 RBC units were transfused, including 2783 in the younger RBC storage group and 2687 in the older RBC storage group. The GEE average relative-effect odds ratio was 0.77 (95% confidence interval [CI], 0.50-1.19; P = .083) for the composite morbidity and mortality endpoint. In-hospital mortality was lower for the younger RBC storage group (2.1% [n = 15] vs 3.4% [n = 23]), as was occurrence of other adverse events except for atrial fibrillation, although all CIs crossed 1.0. ConclusionsThis clinical trial, which was stopped at its midpoint owing to enrollment constraints, supports neither the efficacy nor the futility of transfusing either younger or older RBC units. The effects of transfusing RBCs after even more prolonged storage (35-42 days) remains untested.

Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study.

BackgroundIron deficiency (ID) in pregnancy is a common problem that can compromise both maternal and fetal health. Although daily iron supplementation is a simple and effective means of treating ID in pregnancy, ID and ID anemia (IDA) often go unrecognized and untreated due to lack of knowledge of their implications and competing clinical priorities.Methods and findingsIn order to enhance screening and management of ID and IDA in pregnancy, we developed a novel quality-improvement toolkit: ID in pregnancy with maternal iron optimization (IRON MOM), implemented at St. Michael’s Hospital in Toronto, Canada. It included clinical pathways for diagnosis and management, educational resources for clinicians and patients, templated laboratory requisitions, and standardized oral iron prescriptions. To assess the impact of IRON MOM, we retrospectively extracted laboratory data of all women seen in both the obstetrics clinic and the inpatient delivery ward settings from the electronic patient record (EPR) to compare measures pre- and post-implementation of the toolkit: a process measure of the rates of ferritin testing, and outcome measures of the proportion of women with an antenatal (predelivery) hemoglobin value below 100 g/L (anemia), the proportion of women who received a red blood cell (RBC) transfusion during pregnancy, and the proportion of women who received an RBC transfusion immediately following delivery or in the 8-week postpartum period. The pre-intervention period was from January 2012 to December 2016, and the post-intervention period was from January 2017 to December 2017. From the EPR, 1,292 and 2,400 ferritin tests and 16,603 and 3,282 antenatal hemoglobin results were extracted pre- and post-intervention, respectively. One year after implementation of IRON MOM, we found a 10-fold increase in the rate of ferritin testing in the obstetric clinics at our hospital and a lower risk of antenatal hemoglobin values below 100 g/L (pre-intervention 13.5% [95% confidence interval (CI) 13.0%–14.11%]; post-intervention 10.6% [95% CI 9.6%–11.7%], p < 0.0001). In addition, a significantly lower proportion of women received an RBC transfusion during their pregnancy (1.2% pre-intervention versus 0.8% post-intervention, p = 0.0499) or immediately following delivery and in the 8 weeks following (2.3% pre-intervention versus 1.6% post-intervention, p = 0.0214). Limitations of this study include the use of aggregate data extracted from the EPR, and lack of a control group.ConclusionsThe introduction of a standardized toolkit including diagnostic and management pathways as well as other aids increased ferritin testing and decreased the incidence of anemia among women presenting for delivery at our site. This strategy also resulted in reduced proportions of women receiving RBC transfusion during pregnancy and in the first 8 weeks postpartum. The IRON MOM toolkit is a low-tech strategy that could be easily scaled to other settings.

Red blood cell transfusion associated with increased morbidity and mortality in patients undergoing elective open abdominal aortic aneurysm repair.

BackgroundRed blood cell (RBC) transfusions are associated with increased mortality and morbidity. The aim of this analysis was to examine the association between RBC transfusions and long-term survival for patients undergoing elective open infrarenal abdominal aortic aneurysm (AAA) repair with up to 15 years of follow-up.MethodsProspective cohort study using data from The Danish Vascular Registry from 2000–2015. Primary endpoint was all-cause mortality. Secondary endpoints were in-hospital complications. Transfused patients were divided into subgroups based on received RBC transfusions (1, 2–3, 4–5 or > 5). Using Cox regression multi-adjusted analysis, non-transfused patients were compared to transfused patients (1, 2–3, 4–5, >5 transfusions) for both primary and secondary endpoints.ResultsThere were 3 876 patients included with a mean survival of 9.1 years. There were 801 patients who did not receive transfusions. Overall 30-day mortality was 3.1% (121 patients) and 3.6% (112) for all transfused patients. For the five subgroups 30-day mortality was: No transfusions 1.1% (9 patients), 1 RBC 1.2% (4 patients), 2–3 RBC 2.2% (26 patients), 4–5 RBC 1.9% (14 patients) and > 5 RBC 7.9% (68 patients). After receiving RBCs, the hazard ratio for death was 1.54 (95% CI 1.27–1.85) compared to non-transfused patients. There was a significant increase in mortality when receiving 2–3 RBC: HR 1.32 (95% CI 1.07–1.62), 4–5 RBC: 1.64 (1.32–2.03) and >5 RBC: 1.96 (1.27–1.85) in a multi-adjusted model.ConclusionThere is a dose-dependent association between RBC transfusions received during elective AAA repair and an increase in short- and long-term mortality. Approximately 25% of included patients had preoperative anemia. These findings should raise awareness regarding potentially unnecessary and harmful RBC transfusions.

Implementation of a patient blood management program in hematopoietic stem cell transplantation (Editorial, p. 2763).

Recipients of hematopoietic stem cell transplantation (HSCT) are among the highest consumers of allogeneic red blood cell (RBC) and platelet (PLT) components. The impact of patient blood management (PBM) efforts on HSCT recipients is poorly understood. This observational study assessed changes in blood product use and patient-centered outcomes before and after implementing a multidisciplinary PBM program for patients undergoing HSCT at a large academic medical center. The pre-PBM cohort was treated from January 1 through September 31, 2013; the post-PBM cohort was treated from January 1 through September 31, 2015. We identified 708 patients; 284 of 352 (80.7%) in the pre-PBM group and 225 of 356 (63.2%) in the post-PBM group received allogeneic RBCs (p < 0.001). Median (interquartile range [IQR]) RBC volumes were higher before PBM than after PBM (3 [2-4] units vs. 2 [1-4] units; p = 0.004). A total of 259 of 284 pre-PBM patients (91.2%) and 57 of 225 (25.3%) post-PBM patients received RBC transfusions when hemoglobin levels were more than 7 g/dL (p < 0.001). The median (IQR) PLT transfusion quantities was 3 (2-5) units for pre-PBM patients and 2 (1-4) units for post-PBM patients (p < 0.001). For patients with PLT counts of more than 10 × 109 /L, a total of 1219 PLT units (73.4%) were transfused before PBM and 691 units (48.8%) were transfused after PBM (p < 0.001). Estimated transfusion expenditures were reduced by $617,152 (18.3%). We noted no differences in clinical outcomes or transfusion-related adverse events. Patient blood management implementation for HSCT recipients was associated with marked reductions in allogeneic RBC and PLT transfusions and decreased transfusion-related costs with no detrimental impact on clinical outcomes.

RBC transfusion independence among lower risk MDS patients receiving hypomethylating agents: a population-level analysis

Most patients with lower risk myelodysplastic syndromes (LR-MDS) become red blood cell (RBC) transfusion dependent at some time during their disease course. Hypomethylating agents (HMAs) are frequently used in this setting; however, reported rates of in RBC transfusion independence (TI) achieved with HMA therapy vary significantly between studies. Here we study the real-life clinical effectiveness of HMA in inducing RBC TI in anemic LR-MDS patients using the Surveillance, Epidemiology and End Results (SEER)-Medicare database. We find that approximately 40% of LR-MDS patients who were receiving RBC transfusions and 33% who were dependent on RBC transfusions at HMA initiation ultimately achieved TI. The receipt of ≥3 transfusions in the 8-week period before HMA initiation was significantly associated with lower odds of achieving TI. Our study provides important population level estimates of clinical effectiveness of HMAs in LR-MDS.

PB1963 CHARACTERISTICS OF NEWLY DIAGNOSED AUTOIMMUNE HEMOLYTIC ANEMIA: 5‐YEARS OF SINGLE‐CENTER EXPERIENCE

Background:Autoimmune hemolytic anemia (AIHA) is a rare autoimmune disease in which red blood cells (RBC) are targeted by autoantibodies confirmed with positive direct antiglobulin test (DAT), resulting in premature destruction of RBC. AIHA may be subdivided into warm antibody AIHA (wAIHA) and cold antibody AIHA (cAIHA), and also to primary and secondary depending on the presence of an underlying disorder. In addition to that, patients may have positive DAT but without features of hemolysis, and some of them will later develop AIHA.Aims:The aim of this study was to analyze characteristics of newly diagnosed DAT positive AIHA patients during the 5 years period in our tertiary center, as well to assess DAT positive patients without features of AIHA.Methods:This was a single‐center retrospective cohort study performed at the University Hospital Center (UHC) Zagreb, Zagreb, Croatia, Department of Internal Medicine, Division of Hematology. We included data for all consecutive adult patients with a newly diagnosis of DAT positive AIHA between 2014 and 2018, and also all DAT positive patients without features of hemolysis in that time period. This study was approved by the UHC Ethical Committee. Descriptive statistics was performed and included means ± SD or median (range) as appropriate for continuous variables and frequency (percentage) for categorical variables.Results:The data from 56 patients (50% women) with newly diagnosed DAT positive AIHA during the study period were analyzed. The median age at time of AIHA diagnosis was 67 years (range 22–90 years). Majority of AIHA was wAIHA (51 (91.1%) patients). AIHA was considered primary in only 14 (25%) patients and was associated with an underlying disorder in 42 (75%) patients. The various disorders were associated with secondary wAIHA, the most frequently B‐cell lymphoproliferative malignant diseases (33%), solid tumors (9.8%), myelodisplastic syndrome (9.8%) and autoimmune diseases (9.8%). Median hemoglobin level at the AIHA diagnosis was 71 g/L. 82.1% of patients received RBC transfusion. Seven (12.5%) patients did not require immunosuppressive treatment and other received mostly corticosteroids as the 1st line of therapy. Rituximab received 9 patients (17.6%) with wAIHA, mostly as the 2nd line of treatment. Eight patients (14.3%) with AIHA developed thrombosis (7 with wAIHA and 1 with cAIHA). During the 5‐years study period additional 120 patients with DAT positive results but without signs of hemolysis were detected.Summary/Conclusion:Data from our 5‐years single centre experience with AIHA are comparable with literature data. Majority of patients had secondary AIHA and wAIHA. Rituximab is used mostly as the second‐line treatment and corticosteroid‐sparing agent for wAIHA. Significant number of patients with DAT positive results but without features of hemolysis was detected, and they need to be closely monitored for possible development of AIHA.

A retrospective analysis of venous thromboembolism trends in chemotherapy-induced anemia: Red blood cell transfusion versus erythrocyte stimulating agent (ESA) administration.

e14685 Background: Anemia is a common and unfortunate consequence of chemotherapy; patients receiving a variety of chemotherapy regimens often develop chemotherapy–induced anemia (CIA), which contributes to poor outcomes including increased mortality. Prompt and effective treatment of CIA is essential to prevent fewer chemotherapy dose delays and reductions. Optimal therapy of CIA is controversial and involves the solitary and combined use of intravenous iron, red blood cell (RBC) transfusions, and erythropoietin stimulating agents (ESAs). Despite the baseline coagulopathies present in patients with malignancy, administration of both RBC transfusions and ESAs is associated with venous thromboembolism (VTE). It remains unknown whether the risk of VTE in patients with CIA is greater among patients who receive RBC transfusions or ESAs. Methods: A retrospective single-institution study analyzed 7360 patients with varying malignancies who developed CIA and received ESAs and RBC transfusion from 1998-2017. These patients were evaluated for subsequent development of VTE and categorized by prior receipt of RBC transfusion or ESA. Results: Among the 7360 patients with CIA, 5503 received either RBC transfusion or ESA and 1857 received both. Among all patients, 3466/7360 (47.1%) developed a VTE. The absolute risk of developing a VTE with receipt of a RBC transfusion was 0.38 compared to 0.19 with ESA. Patients with CIA who received RBC had twice the risk of developing a VTE compared with those who received ESA (p &lt; 0.0001). Conclusions: While both RBC transfusion and ESA administration are independently associated with VTE, our data suggests a greater risk of VTE development with RBC transfusion as compared with ESA administration.[Table: see text]

RISK FACTORS FOR BLOOD TRANSFUSION IN WOMEN UNDERGOING GYNAECOLOGICAL SURGERY

Objectives A common complication of surgery is peri-operative blood loss, which increases the likelihood of red blood cell (RBC) transfusion and its associated risks. The objective of this study was to identify demographic, medical, and surgical factors that may predict the need for RBC transfusion in patients undergoing benign gynaecological surgery. Methods We performed a retrospective cohort study of patients undergoing benign gynaecological surgery between April 1st 2016 to March 31st 2017 in a tertiary care hospital. Log binomial regression model was used to calculate risk ratios and adjusted risk ratios, while controlling for the effect of preoperative anaemia. Results Among the 988 patients included, 41 patients (4.1%) received an RBC transfusion and 185 (18.7%) had preoperative anemia. In the total cohort, mean haemoglobin was 126.19+/-15.43g/L, while itwas 104.39+/-21.59g/L among those who received RBC transfusion. Patients had an increased risk of requiring RBC transfusion if they had preoperative anemia (RR 8.37[95%CI 4.48-15.64]), abnormal uterine or vaginal bleeding (RR 2.47[95%CI 1.21-5.03]), underwent vaginal/hysteroscopic myomectomy (RR 6.28[95%CI 1.82-21.69]), or had a salpingectomy (RR 2.13[95%CI 1.01-4.48]). Risk of RBC transfusion was lower among patients with vaginal hysterectomy (RR 0.08[95%CI 0.01-0.57]) and prolapse repair (RR 0.06[95%CI 0.01-0.44]). After controlling for preoperative anemia, only vaginal/hysteroscopic myomectomy showed increased risk of requiring RBC transfusion (RR 3.36[95%CI 1.13-10.01]). Conclusions Preoperative anemia and vaginal/hysteroscopic myomectomy are important independent risk factors for predicting the need for increased RBC transfusion in the peri-operative period. Identifying risk factors can facilitate peri-operative management to minimize the need for transfusion.